Healthcare Provider Details

I. General information

NPI: 1003032434
Provider Name (Legal Business Name): KYLE EUGENE CLYDE LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 MERIDIAN E.
EDGEWOOD WA
98371
US

IV. Provider business mailing address

2809 MERIDIAN E.
EDGEWOOD WA
98371
US

V. Phone/Fax

Practice location:
  • Phone: 253-840-1100
  • Fax: 253-840-1199
Mailing address:
  • Phone: 253-840-1100
  • Fax: 253-840-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00015312
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: